Riding the Telemedicine Wave

HAVASY: On the private insurance side, we’re seeing a rebound for three reasons. No. 1, there are opportunities by arbitraging providers, where some insurers and self-insured employers can find better pricing for routine visits. If you have a company in an expensive area of the country, and you can find care out of state, you can sometimes find lower rates through telehealth.

No. 2, we’re seeing growth in a few specific areas—most notably in behavioral medicine, psychiatry, and counseling—that came from the pandemic. And I think telehealth is popular there because the field is largely full of independent practitioners who are set up to do teleconsults, so they are able to make that work.

The biggest one right now is telehealth being used for things that patients would prefer to avoid doing in person. I live in Massachusetts, and when I ran a large telemedicine program for a big hospital system here, the No. 1 reason anyone over the age of 60 said they prefer a televisit was because they didn’t want to walk on an icy sidewalk in winter. People are also using telemedicine for things they find uncomfortable asking for in person. You see [telehealth company] Hims and Hers as the poster child for that, whether it’s weight-loss drugs, hair-loss drugs, or drugs for erectile dysfunction.

There’s also a huge market for GLP-1s right now because they’re so expensive, even if you have insurance coverage. And I think we’re going to see that getting pushed to alternative providers who may have lower costs for these medications as well as telemedicine management and counseling programs to go along with GLP-1s in ’26 and ’27.

HAVASY: Part of my experience in telehealth was working for a dermatologist at Mass General Brigham (MGB). For dermatology and a few other specialties, telemedicine does two things: it allows you to transcend either time or space. So, you can either interact with a patient in real time when you’re physically separated, or you can speak back and forth with a patient when you’re temporally separated. That works in dermatology because almost nobody says, “Give me a dermatologist, stat.” Instead, you can make a video with the ubiquitous ring lights and 4K technology and you suddenly have a reasonable chance of looking at a lesion or rash and getting a good diagnostic.

Another space is acute primary care. Where I am in the Northeast there is a physician shortage. A number of organizations, including Mass General Brigham, are using teletechnologies coupled with AI chatbots to keep people who no longer have a primary care doctor—because the doctor has left MGB or retired—in their system. MGB is offering an AI-powered telehealth platform where the rest of the primary care doctors in the system share some of those patients’ visits. In primary care, telehealth is getting more usage because you can drive a little bit higher efficiency where there are doctor shortages.

And then the other big one is emergency room follow-ups. We’ve known for a long time that transitions of care are where errors happen. So, if somebody has an emergency room visit that wasn’t for an acute problem, or the person has no primary care doctor to hand off to, the patient would leave with a few slips of paper and be told to make a follow-up appointment, which most people never do. Hospital systems are realizing that providing an easy, low-friction televisit option for that follow-up gives them traction in preventing some of those problems from arising after the handoff from emergency care to primary care.

LEARY: E-prescribing is very helpful to both employers and their workforce. It decreases the amount of time that an employee has to be away for a doctor’s visit, whether it’s a new prescription or a renewal on a prescription. Policymakers hear from a lot of employers that it’s worthwhile to continue to have electronic prescribing available. And if you look at other parts of the world, they’re trying to figure out how to emulate the U.S. [healthcare] system in terms of improving on the percentage of prescriptions that are e-prescribed. It improves patient safety.

HAVASY: E-prescribing does offer an avenue for savings. It allows employees to shop pharmacies. Once the prescription is in the network, that prescription can be directed either by the payer, through their formulary, or by the member to the pharmacy they want. I have a prescription that I get that’s generic and would only cost me $6 at CVS. But I like Mark Cuban’s idea [for reducing the cost of generic drugs], so I send my one little blood pressure prescription to Cost Plus Drug, and I save $1.50 on it. E-prescribing allows that to be my choice. I can decide where to direct it. And that, at scale for a self-insured employer, can generate considerable savings.

LEARY: Well, in 2018—before the pandemic—Rob was the first to argue for giving the secretary of health and human services specific waiver authorities during times of national crises. [This would allow waiving several regulatory requirements for telehealth services that were in place before the pandemic. These included a geography requirement: patients had to be in a provider-shortage area and physically be in a physician’s office to participate in a televisit.] In the spring of 2018, HIMSS wrote a letter saying this should be considered from a preparedness perspective. The organization has advocated for the government to be as creative as possible in making sure that telehealth services are accessible to decrease the amount of stress on the healthcare system, while keeping patient safety protected.

Those are the types of things that CMS [the Centers for Medicare & Medicaid Services] and Congress have tried to think about as creatively as possible. CMS has removed all the barriers [to telehealth] they can without legislative relief. Congress came up with legislative relief [in the form of waivers] during the pandemic, but they haven’t made the commitment beyond that. And the Congressional Budget Office hasn’t made the commitment to making telehealth services available universally for all Medicare patients. So, Congress is the next step. Employers should be emphasizing that Congress needs to take the final step because there is bipartisan support for this.

HAVASY: There’s a strong sentiment in Congress to fix this. But the problem is, it’s buried in a section of the Social Security Act [that details geographic restrictions for telehealth services under Medicare]. I think there’s a worry in Congress that if you open up the Social Security Act for amendments, it turns into a whole big project. And I think it’s that fear of monkeying with this giant piece of legislation that scares a lot of people away from fixing it. It’s not that there’s a huge backlash saying we shouldn’t fix telemedicine.

HAVASY: The rural/urban divide makes for good headlines but not particularly good policy. It depends on what you define as need. It is true that rural areas have less access to specialty care and physician-driven primary care, but there are also not as many rural people. And it’s terrible for them. I grew up in a rural area where my parents would drive two hours to see specialists and plan around snowstorms. But when there are hundreds of millions of urban residents, you have to ask yourself where to put your efforts.

Urban patients benefit substantially from telemedicine as well. In Boston, it may not be an overall lack of providers, but lack of providers who speak a certain language or are in tune with a particular culture. Or, if there is public transportation to get someone to a physician, it may be four bus changes and two hours just to commute a few miles. So, whether it’s an arduous two-hour journey across a cityscape, or an arduous two-hour journey through a snowstorm in Minnesota, that’s still a journey that could be offset by telemedicine.

I think economically it’s going to be the main way primary care is delivered in the future. Unless the U.S. undergoes a fundamental economic restructuring of its [healthcare] system, primary care as we know it as a business is essentially unworkable. Primary care is an unattractive place for people who have to go to school for eight, 10, or 12 years to practice. Last time I checked, 35% of all primary care providers were advanced practice providers [nurse practitioners and physician assistants]. We can’t pay enough for doctors to do it, so they don’t do it, so someone else is stepping into that breach at a lower cost. A lot of hospital systems don’t see the economics of primary care getting better, so they are experimenting with more AI and telemedicine. And that’s why you see the rise of things like Hims and Hers. Wherever primary care is now, it will be disrupted and you’ll see telemedicine is the one doing it.

HAVASY: Their big expenses, like cancer care, aren’t where telehealth is super valuable. I think for employers, telehealth is part of an overall system that can help them reduce friction for employees getting care. And they can find some savings throughout the system, whether it’s arbitraging the pharmacy with electronic prescribing or finding deals for people on recurring maintenance medications by moving them to 90-day supplies at lower-cost pharmacies.

I think there is one important message for employers about telehealth. Early in the pandemic, we saw an absolute age preference for telehealth. Younger people were more likely to use it, and the younger they were, they wouldn’t even need telehealth, they would be happy just texting with their doctors. For employers, as their workforce changes, they will bring the expectation of digitally related care with them, and that’s an important thing for human resource leaders to know and follow. They are going to want to see doctors by televisit and want the option to have their prescription show up at their door just like their Amazon stuff does. I think it’s too late to argue that the trend is not favoring technologically enabled care each and every year as we move forward. The demand for technology-enabled care is on the way up, and I don’t see that changing in the immediate, or far, future.